Ian Simms

Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial

Objective To determine whether screening and treating women for chlamydial infection reduces the incidence of pelvic inflammatory disease over the subsequent 12 months. Design Randomised controlled trial. Setting Common rooms, lecture theatres, and student bars at universities and further education colleges in London. Participants 2529 sexually active female students, mean age 21 years (range 16-27). Intervention Participants completed a questionnaire and provided self taken vaginal swabs, with follow-up after one year. Samples were randomly allocated to immediate testing and treatment for chlamydial infection, or storage and analysis after a year (deferred screening controls). Main outcome measure Incidence of clinical pelvic inflammatory disease over 12 months. Results Baseline prevalence of chlamydia was 5.4% (68/1254) in screened women and 5.9% (75/1265) in controls. 94% (2377/2529) of women were followed up after 12 months. The incidence of pelvic inflammatory disease was 1.3% (15/1191) in screened women compared with 1.9% (23/1186) in controls (relative risk 0.65, 95% confidence interval 0.34 to 1.22). Seven of 74 control women (9.5%, 95% confidence interval 4.7% to 18.3%) who tested positive for chlamydial infection at baseline developed pelvic inflammatory disease over 12 months compared with one of 63 (1.6%) screened women (relative risk 0.17, 0.03 to 1.01). However, most episodes of pelvic inflammatory disease occurred in women who tested negative for chlamydia at baseline (79%, 30/38). 22% (527/2377) of women reported being tested independently for chlamydia during the trial. Conclusion Although some evidence suggests that screening for chlamydia reduces rates of pelvic inflammatory disease, especially in women with chlamydial infection at baseline, the effectiveness of a single chlamydia test in preventing pelvic inflammatory disease over 12 months may have been overestimated. Trial registration ClinicalTrials.gov NCT00115388.

The re-emergence of syphilis in the United Kingdom: the new epidemic phases.

Objective: The objective of this study was to characterize the resurgence of infectious syphilis in the United Kingdom between 1997 and 2003. Study: The authors conducted a retrospective analysis of routine surveillance data from genitourinary medicine clinics and data collected through enhanced surveillance. Results: Between 1997 and 2002, diagnoses of primary, secondary, and early latent syphilis made at genitourinary medicine clinics increased by 213% in heterosexual males, 1412% in men who have sex with men (MSM), and 22% in females. These increases have been driven by a series of outbreaks, the largest of which were seen in Manchester (528) and London (1222) up to the end of October 2003. All the outbreaks have been geographically localized and the majority of cases occurred in MSM. A high percentage of concurrent HIV infection was reported, and oral sex was often reported as a route of transmission. Conclusions: Syphilis has re-emerged in response to behavior change, probably driven by changes in the HIV epidemic. The future course of the epidemic is difficult to predict and control remains elusive.

Bacterial vaginosis: a public health review.

In the UK bacterial vaginosis is one the conditions most commonly associated with an abnormal vaginal discharge in reproductive age women. Bacterial vaginosis is a polymicrobial syndrome in which the normal vaginal lactobacilli, particularly those producing hydrogen peroxide, are replaced by a variety of anaerobic bacteria and mycoplasmas. Common agents of bacterial vaginosis include Gardnerella vaginalis, Mobiluncus, Bacteroides spp. and Mycoplasma hominis. The wide range of possible aetiologies is re ̄ected in the variation in symptoms associated with bacterial vaginosis: these include grey, homogenous vaginal discharge; odorous discharge (®shy smell); increased discharge without an in ̄ammatory response; yellow discharge; abdominal pain; intermenstrual bleeding; menorrhagia or prolonged menses. Up to 50% of women are asymptomatic. This variation is captured by the clinical de®nition of bacterial vaginosis requiring three of the four composite criteria to be met

Lymphogranuloma venereum in the United kingdom.

BACKGROUND Over the past 2 years, lymphogranuloma venereum (LGV), caused by L serovars of Chlamydia trachomatis, has emerged as a significant problem among men who have sex with men (MSM). We report on, to our knowledge, the largest case series of LGV to date, with detailed epidemiological and clinical characteristics of the epidemic in the United Kingdom. METHODS A national diagnostic service and surveillance system was established in October 2004. Cases were confirmed by the presence of C. trachomatis and an LGV serovar (L1, L2, or L3) from genotyping. For confirmed cases, an enhanced surveillance questionnaire was sent to the clinician. RESULTS Through February 2006, a total of 327 cases of LGV were confirmed. Cases were diagnosed across the United Kingdom, with the majority from London (71%) and Brighton (13%). Case reports were received for 282 MSM. The majority (96%) had proctitis, many with severe local and systemic symptoms. There was a high level of coinfection with human immunodeficiency virus (76%), hepatitis C (19%), and other sexually transmitted infections (39%). Nine cases of human immunodeficiency virus infection were diagnosed around the same time as LGV. Most cases were acquired within the United Kingdom, although patients with early cases were more likely to report contacts in The Netherlands. CONCLUSIONS We found a significant burden of this once-rare sexually transmitted infection among MSM in the United Kingdom. LGV may be contributing to the epidemic of human immunodeficiency virus infection by facilitating transmission. Further control efforts are required, including awareness campaigns, continued detailed surveillance, and expanded chlamydia testing among MSM.

Pelvic inflammatory disease epidemiology: what do we know and what do we need to know?

“Pelvic inflammatory disease is a sexually transmitted disease with potentially serious sequelae usually managed badly by doctors with little interest in the condition.” It is a decade since this bleak view of pelvic inflammatory disease (PID) management in the United Kingdom appeared in the BMJ .1 Since then a theme to emerge in sexually transmitted disease (STD) research has been increased awareness of genital chlamydial infection, which causes a substantial proportion of PID cases. In the United Kingdom, this culminated in the Chief Medical Officers expert advisory group on genital chlamydial infection which recognised PID as an important source of preventable reproductive morbidity in women.2 However, little is known of PID epidemiology in England and Wales. The burden of disease and risk factors associated with PID are poorly understood but need to be investigated to inform public health action and clinical practice.3 This paper aims to critically review current knowledge of PID epidemiology with special reference to the United Kingdom and explore the epidemiological research needed to provide an evidence base for PID public health intervention. A literature search was carried out on Medline using the key words “pelvic inflammatory disease” and was repeated using authors known to have published studies concerned with PID and Chlamydia trachomatis . The literature was also trawled for data presentations. PID is the clinical syndrome associated with upper genital tract inflammation caused by the spread of micro-organisms from the lower to the upper genital tract. PID can be caused by genital mycoplasmas, endogenous vaginal flora (anaerobic and aerobic bacteria), aerobic streptococci, Mycobacterium tuberculosis , and sexually transmitted infections (STI) such as C trachomatis or Neisseria gonorrhoeae .4 An association between PID and bacterial vaginosis has also been demonstrated in the absence of C trachomatis and N gonorrhoeae. 5, 6 …

Is Mycoplasma genitalium in Women the “New Chlamydia?” A Community-Based Prospective Cohort Study

BACKGROUND The role of Mycoplasma genitalium in pelvic inflammatory disease is unclear. We conducted a cohort study to determine the prevalence and predictors of M. genitalium infection in female students, to explore its role in pelvic inflammatory disease and to estimate its annual incidence and persistence rate. METHODS Two thousand three hundred seventy-eight multiethnic, sexually active female students (mean age, 21 years) provided duplicate self-taken vaginal samples for a chlamydia screening trial. From this population, 2246 (94%) were followed up after 12 months and assessed for incidence of clinical pelvic inflammatory disease. In addition, 900 women (38%) returned follow-up samples via the postal service 11-32 months after recruitment. Stored samples were tested for M. genitalium. RESULTS The prevalence of M. genitalium at baseline was 3.3% (78 of 2378 women; 95% confidence interval [CI], 2.6%-4.1%). Infection was more common in women reporting ≥ 2 sexual partners in the previous year, those with bacterial vaginosis, women aged < 18 years, women of black ethnicity, and smokers. Multiple partners and bacterial vaginosis were independent risk factors for M. genitalium (adjusted risk ratio, 2.23 [95% CI, 1.39-3.58] and 2.54 [95% CI, 1.61-4.01], respectively). The incidence of pelvic inflammatory disease over 12 months was 3.9% (3 of 77 women) among women with M. genitalium infection, compared with 1.7% (36 of 2169 women) among those without infection (risk ratio, 2.35; 95% CI, 0.74-7.46; P = .14). Annual incidence of M. genitalium infection in 873 women without M. genitalium infection at baseline who returned samples via the postal service was 0.9% (95% CI, 0.5%-1.6%). Seven (26%; 95% CI, 9%-43%) of 27 women with M. genitalium infection at baseline remained positive after 12-21 months; genotyping results suggest that these were persistent infections. CONCLUSIONS M. genitalium infection is unlikely to be a major risk factor for clinical pelvic inflammatory disease in this population.

Associations between Mycoplasma genitalium, Chlamydia trachomatis, and pelvic inflammatory disease

Objective: To evaluate the association between Mycoplasma genitalium, Chlamydia trachomatis, and pelvic inflammatory disease (PID) Methods: A case-control methodology was used. Swab eluates were processed using the QIAamp DNA mini kit. Polymerase chain reaction (PCR) for M genitalium was carried out using a real time in-house 16S based assay. An endocervical swab was taken and tested for the presence of C trachomatis (ligase chain reaction, Abbott Laboratories), and a high vaginal swab was taken and tested for the presence of Neisseria gonorrhoeae and bacterial vaginosis. Results: Of the PID cases 13% (6/45) had evidence of M genitalium infection compared to none of the controls (0/37); 27% (12/45) of the cases had C trachomatis infection compared to none of the controls; and 16% (7/45) of cases only had serological evidence of C trachomatis infection compared to 5% (2/37) of controls. Cases were more likely to present with M genitalium and/or C trachomatis than controls (p<0.001). Conclusions: This study indicates that there may be an association between M genitalium and PID, and that this relation is largely independent of C trachomatis. Future studies need to investigate the pathological basis of the relation between M genitalium and PID using samples from women with PID diagnosed using laparoscopy and endometrial biopsy. Little is known about the epidemiology of M genitalium: large scale epidemiological investigations are needed to determine the prevalence, incidence, and factors associated with this emerging infection.

Trends in sexually transmitted infections in general practice 1990-2000: population based study using data from the UK general practice research database

Abstract Objective To describe the contribution of primary care to the diagnosis and management of sexually transmitted infections in the United Kingdom, 1990-2000, in the context of increasing incidence of infections in genitourinary medicine clinics. Design Population based study. Setting UK primary care. Participants Patients registered in the UK general practice research database. Main outcome measures Incidence of diagnosed sexually transmitted infections in primary care and estimation of the proportion of major such infections diagnosed in primary care. Results An estimated 23.0% of chlamydia cases in women but only 5.3% in men were diagnosed and treated in primary care during 1998-2000, along with 49.2% cases of non-specific urethritis and urethral discharge in men and 5.7% cases of gonorrhoea in women and 2.9% in men. Rates of diagnosis in primary care rose substantially in the late 1990s. Conclusions A substantial and increasing number of sexually transmitted infections are diagnosed and treated in primary care in the United Kingdom, with sex ratios differing from those in genitourinary medicine clinics. Large numbers of men are treated in primary care for presumptive sexually transmitted infections.

Risk of Pelvic Inflammatory Disease Following Chlamydia trachomatis Infection: Analysis of Prospective Studies With a Multistate Model

Our objective in this study was to estimate the probability that a Chlamydia trachomatis (CT) infection will cause an episode of clinical pelvic inflammatory disease (PID) and the reduction in such episodes among women with CT that could be achieved by annual screening. We reappraised evidence from randomized controlled trials of screening and controlled observational studies that followed untreated CT-infected and -uninfected women to measure the development of PID. Data from these studies were synthesized using a continuous-time Markov model which takes into account the competing risk of spontaneous clearance of CT. Using a 2-step piecewise homogenous Markov model that accounts for the distinction between prevalent and incident infections, we investigated the possibility that the rate of PID due to CT is greater during the period immediately following infection. The available data were compatible with both the homogenous and piecewise homogenous models. Given a homogenous model, the probability that a CT episode will cause clinical PID was 0.16 (95% credible interval (CrI): 0.06, 0.25), and annual screening would prevent 61% (95% CrI: 55, 67) of CT-related PID in women who became infected with CT. Assuming a piecewise homogenous model with a higher rate during the first 60 days, corresponding results were 0.16 (95% CrI: 0.07, 0.26) and 55% (95% CrI: 32, 72), respectively.

Risk factors associated with pelvic inflammatory disease

Objective: To investigate factors associated with pelvic inflammatory disease (PID). Methods: A case–control study was used to investigate demographic and behavioural factors, and causative agents associated with PID. Results: A total of 381 participants were recruited: 140 patients, and 105 and 136 controls in tubal ligation and general practice groups, respectively. When compared with a PID-free tubal ligation control group, increased risk of PID was associated with: age <25 years; age at first sexual intercourse <20 years; non-white ethnicity; not having had children; a self-reported history of a sexually transmitted disease; and exposure to Chlamydia trachomatis. When compared with a general practice control group, increased risk was associated with: age <25 years; age at first sexual intercourse <15 years; lower socioeconomic status; being single; adverse pregnancy outcome; a self-reported history of a sexually transmitted disease; and exposure to C trachomatis. Of the cases, 64% were not associated with any of the infectious agents measured in this study (idiopathic). Conclusions: A high proportion of cases were idiopathic. PID control strategies, which currently focus on chlamydial screening, have to be reviewed so that they can prevent all cases of PID. Behavioural change is a key factor in the primary prevention of PID, and potential modifiable risk factors were associated with PID.